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Oghenekome Agbawe

@oghenekomeagbawe

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I review medical necessity, authorizations, and appeals across Medicare, Medicaid, and commercial health plans.

United States

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What I'm looking for

I'm looking for utilization management or review work where I can apply clinical judgment, evidence-based guidelines, and Medicare, Medicaid, and CMS requirements to support timely, medically necessary care decisions.

I support utilization management and medical-necessity decisions for health plans including Molina Healthcare, Acentra, HCSC, Aetna, and Centene. I bring Registered Nurse experience across inpatient, outpatient, behavioral health, home health, skilled nursing, and surgical reviews.

At Molina Healthcare, I assessed services for outcomes, cost effectiveness, benefits, eligibility, prior authorizations, readmissions, and post-claim reviews. I also supported PEGA migration from QNXT and collaborated with multidisciplinary teams on discharge planning and care decisions.

At Acentra, I reviewed 25–30 North Dakota Medicare and Medicaid cases daily, including inpatient, behavioral health, SUD, emergency, rehabilitation, and outpatient requests. I prepared cases for Medical Director review, investigated denials, supported appeals, and referred appropriate members to disease and case management.

I use InterQual, MCG, GuidingCare, Atrezzo, TruCare, Meditech, SmartUM, PEGA, QNXT, and related systems to apply CMS, Medicare, Medicaid, NCQA, HEDIS, and HIPAA requirements. My bedside nursing background in progressive care also informs my clinical judgment, care coordination, and focus on safe patient transitions.

Experience

Work history, roles, and key accomplishments

Utilization Review Float RN

Molina Health Care

Aug 2025 - Jul 2026 (11 months)

Assesses services for members to ensure optimum outcomes, cost effectiveness and compliance with state and federal regulations. Assists in PEGA migration from QNXT to PEGA and performs prior authorization reviews.

Utilization Review Prior Authorizations Medical Necessity Criteria CMS Guidelines Familiarity PEGA QNXT InterQual MCG ICD 10 CPT HCPCS Discharge Planning Case Management

Utilization Review

Acentra

May 2024 - Aug 2025 (1 year 3 months)

Reviews 25-30 North Dakota Medicare and Medicaid claim review cases daily using medical applications such as Atrezzo and InterQual to ensure medical necessity. Prepares cases for Medical Director Review and tracks claim statuses.

Utilization Review Medicare Medicaid InterQual Atrezzo Medical Necessity Criteria CPT HCPCS ICD 10 Appeals Case Management Microsoft Office

Utilization Management

Integrated Resources Inc / HCSC

Aug 2023 - Apr 2024 (8 months)

Reviews medical inpatient/outpatient claims, behavioral health claims, and appeals to ensure medical necessity. Utilizes applications such as Facet, Prepay tool, Availity, GuidingCare, and SmartUM.

Utilization Management Medical Necessity Criteria Appeals Medicare Medicaid MCG GuidingCare SmartUM Facets Availity Prepay ICD 10 CPT HCPCS

Utilization Management

Whitaker IT / Aetna

Dec 2022 - May 2023 (5 months)

Performed pre-authorization, admission, concurrent, and retrospective reviews using Milliman Care Guidelines and Aetna Clinical Policy Guidelines. Also handled appeals and grievances.

Utilization Management Pre Authorization Concurrent Review Retrospective Review MCG Aetna Clinical Policy Appeals Grievances GuidingCare Med Compass SUM()Prepay Cerner

Utilization Management

Pyramid Consulting / Centene Corporation

Sep 2020 - Dec 2022 (2 years 3 months)

Performed prior authorizations requiring medical necessity, utilized McKesson software for claim appeals, and used InterQual for utilization review. Prepared and submitted denial recommendations to medical directors.

Utilization Management Prior Authorizations Medical Necessity Criteria InterQual McKesson GuidingCare TruCare Atrezzo NextGen Healthcare Appeals Case Management

Case Management/Utilization Management RN

Gremmax Staffing

May 2019 - Aug 2020 (1 year 3 months)

Performed concurrent review of clinical information to determine appropriateness and medical necessity of hospitalization and treatments using InterQual criteria. Evaluated patient progress and coordinated care from admission to discharge.

Case Management Utilization Management Concurrent Review InterQual Discharge Planning patient assessment Collaboration

Progressive Care Unit (RN)

Medical City North Hills

Oct 2017 - Apr 2019 (1 year 6 months)

Provided bedside care in PCU, monitored ventilator and telemetry, and administered IV medications including cardiac gtts. Floated to ICU, CVSU, Medsurg, and adult behavioral unit.

Progressive Care Telemetry Ventilator Monitoring IV Medication Administration Cardiac Care patient assessment Critical Care BLS ACLs

Home health Aide

Courages Healthcare Services, Inc.

May 2013 - Aug 2017 (4 years 3 months)

Maintained a safe and healthy patient environment, supported patients with housekeeping and personal services, and helped family members care for patients.

Home Health Patient Care Personal Care Housekeeping Meal Preparation Safety Asepsis